CurrentEmblemHealthPolicy MG.MM.PH.364

Phentolamine and Papaverine (Medicaid only)

Defines Medicaid coverage and prior authorization requirements for phentolamine and papaverine injections for erectile dysfunction and other FDA‑approved non‑ED indications in New York State Medicaid members.

Policy Summary

PayerEmblemHealth

PolicyPhentolamine and Papaverine (Medicaid only)

Policy CodePolicy MG.MM.PH.364

Change TypeNo material change

Effective DateOct 25, 2022

Next Review DateFeb 28, 2025

Key ActionSubmit clinical documentation showing the member meets criteria and verify EDVS status with each prior authorization and renewal.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1 monthMax authorization

2Procedure codes

13+NDCs listed

10Diagnosis codes

Coverage Criteria

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Primary coverage conditions: A. Per the New York State Department of Health guidance, prescription drugs, including phentolamine and papaverine, are not covered by the Medicaid program when prescribed to treat sexual or erectile dysfunction; such drugs are covered only when prescribed to treat a condition other than sexual or erectile dysfunction for which the drug is FDA‑approved.

Verification requirement: B. Erectile Dysfunction Verification System (EDVS) status has been checked.

EDVS verification required on initial request and on each 30‑day renewal.

Authorization duration: C. Prior authorization has been obtained; authorization is limited to 1 month with renewal required every 30 days.1 month

If the patient is on the sex offender list and the request is approved by the medical director, approval must be limited to a maximum 30‑day supply; renewal requires EDVS verification on each request every 30 days.

Coding (HCPCS / NDC / ICD-10)

Applicable Procedure CodesHCPCS

J2440
J2760	Injection, phentolamine mesylate, up to 5 mg

Applicable NDCsNDC

72516-0024-10	Papaverine HCL 30mg/mL Solution
72516-0024-25	Papaverine HCL 30mg/mL Solution
72516-0024-01	Papaverine HCL 30mg/mL Solution
54288-0142-01	Papaverine HCL 30mg/mL Solution
54288-0142-10	Papaverine HCL 30mg/mL Solution
14789-0121-05	Papaverine HCL 30mg/mL Solution
14789-0121-07	Papaverine HCL 30mg/mL Solution
00517-4002-25	Papaverine HCL 30mg/mL Solution
00143-9564-01	Phentolamine mesylate 5mg Solution Reconstituted
00143-9564-10	Phentolamine mesylate 5mg Solution Reconstituted

1–10 of 14

1/2

ICD-10 DiagnosesICD-10

F52.21	Male erectile dysfunction, psychogenic impotence
N52.0	Vasculogenic erectile dysfunction
N52.01	Erectile dysfunction due to arterial insufficiency
N52.02	Corpora-venous occlusive erectile dysfunction
N52.03	Combined arterial insufficiency and corpora-venous occlusive erectile dysfunction
N52.1	Erectile dysfunction due to diseases classified elsewhere
N52.2	Drug induced erectile dysfunction
N52.3	Post-procedural erectile dysfunction
N52.8	Other male erectile dysfunction
N52.9	Male erectile dysfunction, unspecified

Provider Actions and Prior Authorization

Prior Authorization

Prior Authorization and Duration

Prior authorization required. Length of authorization is limited to 1 month. Renewal must be requested every 30 days with verification of Erectile Dysfunction Verification System (EDVS) status on each renewal.

Prior authorization required; authorization limited to 30 days
Renewal required every 30 days with EDVS verification on each renewal

Documentation Required

Documentation Required for Review

The treating physician or primary care provider must submit clinical documentation demonstrating the member meets the policy criteria. Failure to submit necessary clinical evidence will prevent EmblemHealth from properly reviewing preauthorizations or post-payment reviews.

Submit clinical evidence that the member meets the policy criteria
Failure to submit documentation will prevent proper review of preauthorization or post-payment review

Denial Risk

State Medicaid Coverage Exclusion

Per New York State Medicaid guidance, prescription drugs (including phentolamine and papaverine) are not covered when prescribed to treat sexual or erectile dysfunction. These drugs are covered only when prescribed to treat a condition other than sexual or erectile dysfunction for which the drug has been approved by the FDA.

NY State Medicaid: drugs for sexual/erectile dysfunction are excluded from coverage unless prescribed for an FDA‑approved non‑sexual/erectile dysfunction indication
Applies to drugs including phentolamine and papaverine

Definitions

EDVS — Erectile Dysfunction Verification System

TermErectile Dysfunction Verification System (EDVS)

RequirementEDVS status must be checked and verified on requests for phentolamine and papaverine per policy

ContextPer NY State Department of Health guidance, these drugs are not covered by Medicaid when prescribed to treat sexual or erectile dysfunction unless used for a non‑ED FDA‑approved indication

Verification timingEDVS verification is required on initial request and on each 30‑day renewal

Related actionFailure to verify EDVS status may result in denial of authorization or payment

Background

Background: New York State Department of Health guidance excludes phentolamine and papaverine from Medicaid coverage when prescribed for sexual or erectile dysfunction. These agents may only be covered when prescribed to treat a condition other than sexual or erectile dysfunction for which the drug is FDA‑approved; providers should document the non‑ED indication when submitting authorization requests.